Contact Information

Please be sure to provide your name exactly how it reads on your dental license. If you have a middle initial on it, be sure to include that as well. If it does not match the system, you will not get credit for the course.

NAME*

FirstLast

M.I.

Credentials*

Credentials: Other (Please Specify)

COURSE TO ATTEND

Child Abuse Course: 9:00 AM – 11:00 AM

Street Address

City

State

Zip Code

*

Email

*

Phone

Fax

REQUIRED INFO FOR LICENSED PROFESSIONALS

Prof. License #:

Date of Birth:

Last 4 Digits of SSN:

Additional Guest Information

Please be sure to provide your name exactly how it reads on your dental license. If you have a middle initial on it, be sure to include that as well. If it does not match the system, you will not get credit for the course.

1.) GUEST NAME

FirstLast

M.I.

Guest Credentials

Credentials: Other (Please Specify)

COURSE TO ATTEND

Child Abuse Course: 9:00 AM – 11:00 AM

REQUIRED INFO FOR LICENSED PROFESSIONALS

Prof. License #:

Date of Birth:

Last 4 Digits of SSN:

Please be sure to provide your name exactly how it reads on your dental license. If you have a middle initial on it, be sure to include that as well. If it does not match the system, you will not get credit for the course.

2.) GUEST NAME

FirstLast

M.I.

Guest 2 Credentials

Credentials: Other (Please Specify)

COURSE TO ATTEND

Child Abuse Course: 9:00 AM – 11:00 AM

REQUIRED INFO FOR LICENSED PROFESSIONALS

Prof. License #:

Date of Birth:

Last 4 Digits of SSN:

Please be sure to provide your name exactly how it reads on your dental license. If you have a middle initial on it, be sure to include that as well. If it does not match the system, you will not get credit for the course.